National Non-VA Medical Care Program Office
Veteran Directed - Home and
Community Based Services (VD-HCBS)
Procedure Guide
June 01, 2015
Version 1
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Table of
Contents
Veteran Directed - Home and Community Based Services (VD-HCBS) Overview ....... 3
Policy Change .............................................................................................................. 3
Specific Services in VD-HCBS ..................................................................................... 4
Exemptions from VD-HCBS Billing .............................................................................. 4
Entering a VD-HCBS Authorization.............................................................................. 4
VD-HCBS Acronyms & Terminology ............................................................................ 5
VD-HCBS Features...................................................................................................... 7
Billing Responsibilities of the VAMC and the Aging and Disability Network Agency . 10
Billable HCPCS Procedure Codes ............................................................................. 11
Resources .................................................................................................................. 11
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Veteran
Directed - Home
and Community
Based Services
(VD-HCBS)
Overview
Veteran Directed - Home and Community Based Services (VDHCBS) is a home and community based service (HCBS) for
Veterans who need significant support to remain safely in the
community. As a participant-directed program it allocates a
budget to the Veterans to pay for their care. The amount of this
budget is based on their score on the Purchased HCBS Case
Mix and Budget Tool. Further, VD-HCBS operates as a
partnership between the local Veterans Affairs Medical Centers
(VAMC) and the local Aging and Disability Network. As a result,
all bills for this program are generated by the Aging and
Disability Network Agency.
This procedure guide provides an overview of a standardized
new claim processing requirements for all VD-HCBS claims
processed with a date of service on or after February 1, 2015.
Policy Change
Since Veterans can pay for a wide range of goods and services
with their budget, the VA has been working with various
approaches to billing for VD-HCBS services since the
program’s inception in 2009. Now, all billing will have to follow
the procedures described in this document. All VD-HCBS
claims with dates of service on or after February 1, 2015, must
use the procedures described here. Claims with dates of
service prior to February 1, 2015 will be processed based on
local procedures that were in effect prior to November 1, 2014.
This rule change does not impact current contracts or sharing
agreements that VAMCs may currently have in place, created
prior to February 01, 2015.
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Specific
services in
VD-HCBS
While a Veteran receiving VD-HCBS may benefit from a wide
range of self-directed services, bills from the Aging and
Disability Network provider will all fall under one of two
services.
Personal Care Services are services provided to support the
health and wellbeing of an individual in their home. For VDHCBS, all services that support the Veteran during the billing
period will be combined and billed as a daily average cost.
These will include the monthly costs incurred by the Aging and
Disability Agency.
Service Assessment/ plan of care development (case
management) are the initial assessment and case set-up fees
that go to the Aging and Disability provider as a one-time
payment at the beginning of VD-HCBS services being
provided. These include a partial assessment fee for Veterans
who use the services of the Aging and Disability provider but
do not enroll in VD-HCBS or a full Service Transition and
Assessment Reimbursement (STAR) for Veterans who enroll in
the program.
Exemptions
from VD-HCBS
Billing
There are no exceptions for VD-HCBS. All services delivered
must be billed as one of the two services listed above.
Entering a
VD-HCBS
Authorization
• VD-HCBS must be pre-authorized by the VAMC, although
the authorization does not need to be from a physician. The
authorization will come from the VD-HCBS Program
Coordinator at the VAMC and will include:
o The Amount of the STAR and Partial Assessment fee.
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o The Veteran’s yearly allocation (Note: monthly bills may
be more or less than the allocated amount since Veterans
may underspend in one - or more - months in order to be
able to make a large expenditure which supports their
care)
Refer to the Purpose of Visit (POV) Information & Table for a
complete list of codes.
VD-HCBS
Acronyms &
Terminology
The following list of acronyms and terminologies is specific to
the VD-HCBS program.
Aging and Disability Network Agency – The local agency
who is designated as a provider by the VAMC that provides
Options Counseling and Financial Management Services to the
Veteran.
Budget – The monthly amount allocated for the Veteran to
spend to acquire their long-term care services and supports.
Financial Management Services – Financial Management
Services (FMS) are those services that assist Veterans’
managing their budgets. FMS provide payroll services to
assure that hired workers are paid appropriately and reimburse
purchases of the Goods and Services using the Spending Plan
as the guide to determine which services are authorized by the
VAMC. Fees for the FMS are included in the Aging and
Disability Network provider’s administrative fees.
Goods and Services – Goods and Services refer to items in a
Spending Plan which includes professional services (other than
Direct Care) as well as supplies and durable goods which
support the Veteran’s safety, wellbeing and independence. All
purchases of Goods and Services are approved by the VAMC
VD-HCBS Coordinator when they approve the Spending Plan.
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Monthly Administrative Fees – Agency Administrative Fees
as monthly fees paid to the Aging and Disability Network
Agency to pay for their provision of direct services to the
Veteran. These fees are set by the VA and are included in the
agreement between the VAMC and the local Aging and
Disability provider. They come out of the Veteran’s Budget and
are reflected in the Spending Plan.
Options Counseling – Veterans in VD-HCBS receive direct
support from the Aging and Disability Agency in the form of an
individual who carries out the person-centered assessment,
assists in the development of the Spending Plan and
periodically monitors the Veterans wellbeing. This person is
referred to as the Options Counselor.
Participant Direction: Participant Direction is a method of
providing long-term services and supports (LTSS) where
Veterans receiving the services are given a high level of choice
in determining their service package. This includes hiring their
own workers and purchasing goods and services from a predetermined budget and spending plan. In Participant Direction
the Veteran receiving the services or their designated
representative is the employer or co-employer of the workers
who care for the Veteran.
Personal Care Services – In a Spending Plan, Personal Care
Services are hands-on care provided by a worker hired by the
Veteran or the Veteran’s representative.
Purchased HCBS Case Mix and Budget Tool – An
assessment tool which determines the Veteran’s level need for
home services. That need level, in turn, determines the amount
of the Veteran’s Budget and associated STAR Fee.
Savings – Money that a Veteran does not spend from his or
her Budget in a given month may, within limits, be kept
available to the Veteran in the form of savings. The actual
savings are held by the VAMC but the accounting related to the
savings is maintained by the FMS. Savings may include
•
Specified savings which are savings to make a planned
large purchase (such as a home modification) or
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•
Emergency savings which are savings for unexpected
expenses, such as increased care hours should the Veteran
fall ill.
Spending Plan – An individualized plan based on a personcentered assessment process which describes how the
Veteran will use the budget each month. The Aging and
Disability Agency, working with the Veteran or their designated
representative, develops the spending plan before transmitting
the plan to the VAMC for approval. The spending plan may
include personal care, goods and services, savings and agency
administrative fees.
VD-HCBS
Features
VD-HCBS is a participant directed program where the Veteran
is awarded a budget based on his or her care needs. The
Veteran then develops a spending plan to determine how the
budget will be used. As a participant-directed program,
Veterans in VD-HCBS hire the workers who provide their
personal care, determining the hours they work and their
wages. The Veteran may also purchase goods and services to
help meet their needs.
Veterans in VD-HCBS are supported by Options Counseling
and FMS provided by an Aging and Disability Network provider
who is identified by the VAMC.
Distinct features of VD-HCBS include:
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Partnership between Local VAMCs and Aging and
Disability Network Agencies
While VD-HCBS is a service of the Veterans Health
Administration (VHA), direct Veteran oversight and support is
provided by a local Aging and Disability Network Agency.
These agencies go through a process to determine their
readiness to support Veterans in the program and are
designated by the local VAMC as Providers.
Budget Determination Using the Purchased HCBS Case
Mix and Budget Tool
At the time of referral to VD-HCBS, the VAMC determines the
Veteran’s budget through the use of the Purchased HCBS
Case Mix and Budget Tool. The Purchased HCBS Case Mix
and Budget Tool is used to determine the Veteran’s levels of
need with an assigned budget category to that need level. The
specific budget amounts vary locally and are set by the VA
based on local wage rates for care as determined by the
Centers for Medicare and Medicaid Services (CMS).
STAR and Partial Assessment Fee
Upon completion of the Spending Plan and the beginning of
services, the Aging and Disability Network Provider may bill a
Service Transition and Assessment Reimbursement or STAR
Fee. This is designed to cover costs associated with transition
and admission of a new referral. However, since VD-HCBS
requires Veterans take significant responsibility for managing
their care, some Veterans may, upon learning the details of the
program, choose not to enroll. In that case, the Aging and
Disability Network provider may bill for a Partial Assessment
Fee to cover the costs of their working with the Veteran.
Monthly Per-Diem Billing Based on Actual Spending
VD-HCBS Personal Care Services are billed on the basis of a
per-diem charge which is based on the actual costs the
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Veteran generated in a given month divided by the number of
days in the month that the Veteran received services. A
Veteran will rarely spend exactly their budget amount in a given
month. Actual spending may vary depending on days of the
month, the amount of care a Veteran received in a given month
and whether the Veteran is adding to or drawing down his or
her savings. As a result, the per diem amount that is billed will
vary from month to month.
Monthly Expense Report
Each month, the VD-HCBS coordinator at the VAMC receives a
detailed report of the Veteran’s spending for the previous
month which spells out all the hours of care the Veteran
received and the wage rate, all purchases of goods and
services the Veteran may have made, all savings accrued and
spent, and all administrative fees. If the VD-HCBS Program
Coordinator sees a discrepancy between the spending plan
and what was actually spent over the course of the month, the
Program Coordinator will direct the Aging and Disability
Network provider to review the case mix spending plan and,
when appropriate, adjust to reflect the care needs of the
Veteran.
Reconciliation at the End of Services
When a Veteran leaves VD-HCBS for whatever reason, the
Aging and Disability Network Provider may have excess funds
at the time of their final bill. The local VD-HCBS coordinator will
take that into account when reviewing the final Quarterly
Report from the Aging and Disability Provider and coordinate
with their business office to issue a bill of collection.
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Billing
Responsibilities
of the VAMC
and the Aging
and Disability
Network
Agency
The VAMC is responsible for:
• Identifying and referring Veterans to VD-HCBS
• Determining the Budget amount using the Purchased
HCBS Case Mix and Budget Tool
• Developing an agreement with the local Aging and
Disability Network to designate them a provider of VDHCBS services
• Reviewing quarterly reconciliation reports to assure
appropriate expenditure of funds
• Reimbursing the provider in a timely and accurate manner
The Aging and Disability Network Agency is responsible
for:
• Assisting the Veteran in developing a spending plan using
person centered approaches
• Educating and supporting the Veteran in the role of
employer
• Providing Financial Management Services
• Engaging in on-going monitoring of the Veteran’s receipt of
services and their wellbeing
• Billing the VA timely and accurately
• Developing and submitting monthly detailed expense
reports to the VAMC VD-HCBS Coordinator
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Billable HCPCS
Procedure
Codes
T1020 – Personal Care Services
All expenses that relate to the care of the Veteran, including
the Aging and Network Agency’s administrative fees, are billed
under this code. The description of how the per diem rate is
determined can be found on pages 5 - 6 under “Monthly PerDiem Billing Based on Actual Spending.”
T2024 – Service Assessment/plan of care development
The Partial Assessment Fee and the STAR will be billed here,
with whether the bill is for the Partial Assessment Fee or the
STAR to be noted in the “comments” section.
For further guidance on completing the Centers for Medicare
and Medicaid Services (CMS) – 1450 Form, please refer
to Medicare Claims Processing Manual Chapter 25 Completing and Processing the Form CMS-1450 Data Set.
Resources
Case Mix and Budget Tool
Medicare Claims Processing Manual Chapter 25 - Completing
and Processing the Form CMS-1450 Data Set
Purpose of Visit (POV) Information & Table
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